According to ambulance paramedic Trevor Storey, the 5 year-old boy was hit by a car at 65 km/h, enough force to send his tricycle flying 40 feet. The passerby who found him did their best to perform CPR as they waited for the ambulance and told the medics when they arrived that the boy had appeared to die briefly, but the CPR attempts apparently brought him back. As they raced him back to the hospital, Storey and his partner Trevor Kidd call ahead to have a flight crew meet them at Emergency. With the extent of the little boy’s injuries he’ll need to be airlifted away to Sick Kid’s in Toronto.

Standing in the Emergency Room I watched as the paramedics were met by the air ambulance team, Mary Thibeault and Mike Tesarski, who decide to have the boy wheeled into one of the stalls for analysis. They need to make sure he can survive the trip before they load him into the helicopter. A quick check with the small town hospital staff confirms that their two doctors are already involved with other emergencies and it will be up to the paramedics to treat the patient on their own.

As the boy is connected up to a monitoring station, a call is sent out to a beeper on one of eight on-call doctors across the province who will guide the medics through the needed care for the little boy. These are specially trained Critical Care Paramedics who can perform tasks normally reserved for doctors. They will become the eyes and ears for the doctor in Toronto who can license them to perform a number of necessary procedures that would normally have to wait until after the helicopter ride, a delay which in this case would be fatal.

Strapped to a hospital bed with a neck brace already in place, the little boy barely moves, but gives out a small groan. The ambulance team passes on the information that the boy has been displaying a decreased level of awareness.

“Can you tell me where it hurts?” asks Mary who quickly opens his eyes to check his pupils while gently feeling along his body for trauma. The boy merely groans, unable to form an answer. At first it looks as if the injuries are not as bad as thought, his eyes are clear when Mary looks at them, but a few moments later the boy’s oxygen levels drop rapidly and his groans become quiet. Her partner Mike takes a second look at the boy’s eyes and notices that the left pupil is now blown, an indicator of possible brain injury.

Over the next tense fifteen minutes I watch the medics move quickly to respond to the boy’s rapidly changing condition, inserting chest needles to keep his lungs inflated and pushing a ventilator tube down his throat to keep his airway clear in the need of keeping the boy’s oxygen levels up to prevent further brain injury.

Mary Thibeault, Mike Tesarski, and Trevor Storey work to save a little boy's life

Over a crackly speaker the on-call voice of Doctor King comes through from more than 200km away. After the flight medics give him a quick rundown of the boy’s condition, he gives them his recommendations and grants them permission for the chest needles and for a breathing tube to be inserted into the boy’s trachea. More than once, he and the medics exchange a “Can you repeat that please” or a “Speak up I didn’t hear that” as they work to communicate through a remote phone connection.

After the boy goes into cardiac arrest, Dr. King grants them license to use medications to bring the boy to a stable condition. Once it appears the boy will stay alive for the next hour, they begin to move him for the flight.

And that is where the simulation ends.

None of the story I’ve just told you is true. There was no accident and the paramedics are actually students in training. As you can see from the photos, the hospital was real, the sheets were real, the monitors, the chest needles, ventilator, even the medication flowing from the bags and into the boy’s veins were real. The room itself is fake. Standing as I was at the foot of the bed, I only needed to open a door to my left and I’d walk right out into an empty parking lot, no hospital in sight. Although everything in the room worked, the Emergency stall itself was a mock-up, placed inside the cargo hold of a transport trailer, not even a proper building.

A door opens and in walks their instructor, Kevin King, who watched the entire emergency play out through a video camera feed from a nearby observation room. He immediately engages the students in a discussion of their performance, going over each of their treatment decisions and reminding them of areas for improvement. In this case the students were late in requesting the arrangements to have a blood supply waiting for them on landing. A minor mistake, but even the little things can have major consequences.

Kevin King, Medical Instructor and Manager of the Ornge Simulation Program Watches From The Simulation Control Room

The little boy is a very special kind of fake. An artificial human, complete with working lungs, circulatory system, pulse, dilating pupils, rising and falling chest, all of which will react depending on the kind of medication you inject into him.

If the monitor systems used could speak, they would tell you they were connected to a real boy, one that inhaled air, and exhaled carbon dioxide. They would tell you that the changing heart rate and blood pressure readings match those of a real 5 year-old and the moment when he went into cardiac arrest was just as disturbing, because this fake boy can also die. If he were to flat line for good, nothing in the world could get his robotic eyes to flutter open again, he’d be lifeless, until the instructor flipped his reset button.

This is the Ornge Simulation Trailer, a mobile training centre designed to provide immersive, hands-on exercises for nurses, doctors, and paramedics. It is designed to be taken out on the road and parked in small rural areas across the province of Ontario, assuring that staff at every medical centre and town hospital receive the same level of training as medical staff in the big cities.

In addition to the false Hospital Emergency Room, the trailer also contains a mock-up of the interior of a land ambulance as well as an S-76 air ambulance helicopter, all equipped with working instruments, monitoring units, and designed to match the same cramped quarters of the real thing.

These mock-ups are specifically designed to train a new generation of mobile medical staff called “Critical Care Paramedics”. Their new role in the medical community is to go beyond the normal duties of an air ambulance paramedic and, thanks to mobile communications, be the hands, eyes, and ears for doctors, providing physician-level care in situations where a doctor is absent. For the handful of paramedic students chosen to take the accredited program, it means having to complete four additional years of training.

The six students I met with, Trevor Storey, Trevor Kidd, Mike Tesarski, Mike Curry, Mary Thibeault, and Steve Wiebe are all nearing the end of their training and will become the next six Critical Care Paramedics to enter Ontario’s medical community.

The trailer is used at first to give instruction, to allow students an exact working environment to learn how to perform manual procedures, such as inserting a breathing tube or applying a neck brace, but once these instructions are over, the simulation becomes a testing ground. The students are then summoned to the trailer for practice scenarios like the one I described at the beginning of this article. The door to the trailer opens, the students walk in alone with no idea what awaits and the door closes behind them. There’s no instructor in the room, just an artificial patient, could be a man, a woman, a child, they have no idea, and it’s up to them to physically examine the patient, diagnose the problems, and act on treating them.

Since failure is part of the equation, there are many times when the students emerge from the trailer distraught over the death of the artificial human inside. “I’ve actually had students crying when they come out of here and feeling really despondent and dejected” King tells me, a testament that the emotional impact of the simulation environment is greater than they’ve seen with other training courses. Its an element that he feels is ideal as part of the goal is to teach the students how to emotionally cope and deal with the pressure of emergencies as much as it is to coach them in manual procedures.

The students themselves have nothing but praise for the experience.

“This is the way of the future” Mike Tesarski tells me. “How we used to train, before four years ago, we’d go in and they’d have a mannequin or someone pretending that they were hurt, but they don’t really react to the medicine, they don’t really breathe, you can’t really stick needles into them, you can’t put a tube into their trachea, so for these high acuity, big problem calls, that don’t happen all the time, you practice them here.”

Traditional training scenarios can often resemble acting classes with students miming out actions for each other, forcing students to have to try to pause as they visualize what they are doing and take in information that may be read off to them from a clipboard by an instructor. By contrast, the Simulation Trailer delivers information as it would in the real world, right from the body of the patient and the LED read-outs of the monitoring equipment.

“You have to actually perform the skill” Mary Thibeault says of the difference. “It isn’t like, verbalizing the action.”

“And quicker. We see almost immediate changes’ adds Tesarski, “which makes it a better learning tool because then you have to think quicker. When the stats can immediately change by the medication we just gave, then we have to react immediately to it as well”

“It used to be that medical school students who are training to become doctors, would learn to be good at doing scenarios, but not necessarily become good at caring for patients because the scenarios weren’t realistic enough” explains Mike Curry. “The more realistic we make the scenarios, and you become good at doing them, then you’ll also become good at handling real patients.”

The scenarios are designed to be unpredictable, so that, the students could be sent into the trailer once again to treat a 5 year-old car accident victim, but have a completely different experience, from the way that the boy’s stats would fluctuate to physical changes in the artificial body which is designed, for example, to simulate a swollen tongue or seized vocal chords, both conditions that will make it harder for the students to physically insert the breathing tube into the artificial throat.

“What I like to focus on is critical thinking skills” says Kevin King who is also manager of the Ornge Simulation Program. “It’s one thing to teach you how to put a tube down a patient’s throat, but I want you to understand why you’re doing it and when the time should come that you would do that. With all hand-based skills I’m more concerned that you know when to perform them. So we will build that type of conundrum problem so that you’re forced to think ‘Should I do this, or shouldn’t I do this?”

To replicate the kind of twists that medical staff are faced with in real life, King and his partners collect stories and data from real emergency rooms where doctors are encouraged to submit unusual or challenging cases that can then be recreated within the trailer as scenarios for doctors throughout the province to try.

They will also include confusing information and sometimes recruit actors to behave as hysterical relatives inside the trailer to add emotional pressure to the exercise. In the scenario I described, they purposely included the confusing story of passerby apparently bringing the boy back from the brink of death through CPR, information that could be false, exaggerated, or true.

And yes, they will set up a random experience where, despite the students doing everything right, the patient still dies, just as it sometimes happens in real life. The discussion group that follows between student and teacher is designed to help them cope with that reality.

The results are best expressed with this story by student Mike Curry who had experience as a land ambulance paramedic before entering the program to become a helicopter medic.

“There was a call that surprised me one time, because I walked into the testing scenario and the patient was acting exactly the same way as a patient I had three or four months previous that had been a really heavy, hectic call. I hadn’t e-mailed the details of that call to Kevin or anybody to say ‘Turn this into a scenario’, but somehow it ended up that this patient in the scenario was very similar to this patient that I had just treated and that really shocked me, because I was like ‘Wow, this really is realistic, this is déjà vu. The way that I was treating the mannequin in the scenario, she was reacting similar to the way the real patient reacted.”